Brainstem involvement in hypertensive encephalopathy

Cruz‐Flores, Salvador; Gondim, Francisco de Assis Aquino; Leira, Enrique C.

doi:10.1212/01.wnl.0000120668.73677.5f

Cited by 64 publications

(60 citation statements)

References 8 publications

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“…In our case, the patient developed supranuclear horizontal gaze palsy given the intact vestibulo-ocular reflex. This palsy was mostly due to an impairment of the cortical gaze center in the frontal lobe (6)(7)(8).…”

Section: Discussionmentioning

confidence: 99%

Posterior reversible encephalopathy syndrome associated with left horizontal gaze palsy

et al. 2017

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Posterior reversible encephalopathy syndrome (PRES) is characterized by rapid onset of symptoms including headache, seizures, altered consciousness, and visual disturbance, as well as radiologic findings of focal reversible vasogenic edema. Multiple visual disturbances have been described in PRES, such as hemianopia, visual neglect, auras, visual hallucinations, and cortical blindness. However, horizontal gaze palsy has not been previously reported. We report a 72-year-old female who presented with blurred vision, severe headache, lethargy, and later developed seizures. She was found to have left horizontal gaze palsy with intact vestibulo-ocular reflex. Brain magnetic resonance imaging (MRI) showed severe edema throughout the subcortical white matter, and signal in the posterior parietal and occipital lobes. She was diagnosed with PRES associated with supranuclear gaze palsy. Case presentationA 72-year-old female presented to the emergency department with a one-day history of recurrent falls and lethargy. She attributed her falls to tripping on things she didn't see. Her complaints were associated with constant, severe headache that was unresponsive to analgesia. No other significant symptoms were reported. She had a past medical history of coronary artery disease, peripheral artery disease, hypertension, and dyslipidemia.Her vital signs showed a blood pressure of 230/80 mmHg, heart rate 76/min, oxygen saturation of 99%, and temperature of 97.4. On examination, she was confused with slowed responses and oriented only to person. She had impaired remote memory and concentration. Her neurological examination was significant for left horizontal gaze palsy with intact vestibulo-ocular reflex, and right lower limb weakness with brisk right lower limb reflexes. No other focal neurological deficits were seen. The rest of her examination was unremarkable.Blood workup including blood count, electrolytes, renal function, thyroid function, and rheumatological markers were insignificant. Brain computed tomography (CT) scan didn't show any acute pathology. The blood pressure was slowly lowered in the emergency department, and she was admitted for further workup and evaluation.On the night of her admission, the patient developed a simple partial seizure with left upper limb tonic-clonic movements. Three doses of lorazepam, and fosphenytoin failed to control the seizures, which lasted for more than 20 minutes, and the patient required intubation. Repeat brain CT scan showed low density in the subcortical white matter in the parietal and occipital lobes (Figure 1). Subsequent magnetic resonance imaging (MRI) of the brain showed severe edema throughout the subcortical white matter, and increased signal in the posterior parietal and occipital lobes with lesser involvement of the frontal lobes and lateral temporal lobes (Figure 2).She was successfully extubated on the following day. During her hospital stay, the lateral gaze resolved and her mental status continued to improve. Follow up head CT scan showed near complete...

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Section: Discussionmentioning

confidence: 99%

Posterior reversible encephalopathy syndrome associated with left horizontal gaze palsy

et al. 2017

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“…6,22,33) Shunt placement was required for hydrocephalus in one patient and another patient underwent ventriculostomy. 7,27) The latter patient died after developing sepsis. Therefore, early diagnosis and treatment are quite important.…”

Section: Case Reportmentioning

confidence: 99%

Blurred Vision With Acute Hypertension Indicating Hypertensive Brainstem Encephalopathy -Case Report-

Ogaki

Fukae²,

Noda³

et al. 2009

Neurol. Med. Chir.(Tokyo)

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A 49-year-old woman presented with hypertensive brainstem encephalopathy (HBE) manifesting as visual disturbance and papilledema but no other neurological abnormal findings. Magnetic resonance (MR) imaging showed extensive lesions in the brainstem and bilateral thalami but not in the occipital lobes. The patient also had renal failure and underwent hemodialysis. Her visual disturbance and MR lesions resolved rapidly after antihypertensive treatment. This case of HBE only caused visual disturbance despite the presence of massive brainstem edema. The presence of fetal-type posterior cerebral artery may have spared the occipital lobe. Clinicians should consider HBE in hypertensive patients with blurred vision. HBE is reversible if immediate antihypertensive treatment is initiated, but neurological sequelae may develop if treatment is delayed.

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“…PRES rarely presents with predominant involvement of the brain stem, and involvement of only the medulla oblongata is uncommon. 2,3 Only 1 patient with PRES was reported to have medulla oblongata, upper cervical spinal cord, and supratentorial involvement. 4 Herein we report 2 cases of a presumed variant of PRES with only medulla oblongata involvement.…”

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MR Imaging Findings of Medulla Oblongata Involvement in Posterior Reversible Encephalopathy Syndrome Secondary to Hypertension

Chen¹,

Lee²,

Wu³

et al. 2008

AJNR Am J Neuroradiol

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SUMMARY:Although the combination of MR imaging findings and clinical evidence of hypertension may suggest the diagnosis of posterior reversible encephalopathy syndrome (PRES), MR imaging findings with only involvement of the medulla oblongata pose a diagnostic dilemma. In the cases presented here, we demonstrated MR imaging findings of a presumed brain stem (medulla oblongata) variant of PRES and emphasized the diagnostic value of diffusion-weighted imaging (DWI). Posterior reversible encephalopathy syndrome (PRES) is characterized by headache, vomiting, altered consciousness, seizure, and cortical blindness associated with imaging findings of predominantly posterior bilateral symmetric subcortical and cortical edema without frank infarction.1 Hyperintense lesions on T2-weighted MR imaging and swelling of the brain stem may be related to many different pathologic processes. PRES rarely presents with predominant involvement of the brain stem, and involvement of only the medulla oblongata is uncommon.2,3 Only 1 patient with PRES was reported to have medulla oblongata, upper cervical spinal cord, and supratentorial involvement. 4 Herein we report 2 cases of a presumed variant of PRES with only medulla oblongata involvement. Case Reports Case 1A 59-year-old man with history of left putaminal hemorrhage 15 years previously had a 1-week history of poor appetite, vomiting, altered consciousness, and seizure-like movements. His history was also significant for hypertension controlled with medications. Initial blood pressure (BP) was 210/108 mm Hg. Serum electrolytes were normal. Brain MR imaging (Signa LX2; GE Healthcare, Milwaukee, Wis) revealed isointensity on T1-weighted images (T1WIs) and diffusionweighted images (DWIs), and hyperintensity on T2-weighted images (T2WIs) of the medulla oblongata and upper cervical spinal cord (Fig 1). Because of clinical signs and history and MR imaging findings of edema (not infarction) in the medulla oblongata and upper cervical spinal cord, the differential diagnosis included a variant of PRES, encephalitis, and encephalomyelitis. Because there was no evidence of infection or fever, and results on CSF examination were unremarkable, a variant of PRES was the likely diagnosis. An angiotensinconverting enzyme inhibitor and a calcium channel blocker were administered for BP control. His clinical condition improved, BP normalized to 140/90 mm Hg, and level of consciousness returned to normal. MR imaging 45 days later (Fig 1) indicated resolution of hyperintensity confirming a variant of PRES secondary to hypertension with involvement of the medulla oblongata. Case 2A 62-year-old man with a history of hypertension and cerebral infarction was seen with a 3-day history of headache, vomiting, involuntary movement, and change in consciousness. BP was 180/100 mm Hg. No signs of infection or a meningeal abnormality were present, and serum electrolyte levels and CSF were normal. Brain MR imaging showed hyperintensity on T2WIs and isointensity on DWIs, which involved the medulla oblongata (Fig ...

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Brainstem involvement in hypertensive encephalopathy

Cited by 64 publications

References 8 publications

Posterior reversible encephalopathy syndrome associated with left horizontal gaze palsy

Posterior reversible encephalopathy syndrome associated with left horizontal gaze palsy

Blurred Vision With Acute Hypertension Indicating Hypertensive Brainstem Encephalopathy -Case Report-

MR Imaging Findings of Medulla Oblongata Involvement in Posterior Reversible Encephalopathy Syndrome Secondary to Hypertension

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